CERTIFICATIONS, ASSURANCES, AND OTHER STATEMENTS

OF APPLICANT/RECIPIENT1
1. ASSURANCE OF COMPLIANCE WITH LAWS AND REGULATIONS GOVERNING
NON-DISCRIMINATION IN FEDERALLY ASSISTED PROGRAMS

(a) The applicant/recipient hereby assures that no person in the United States shall, on the bases set forth below,
be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under, any
program or activity receiving financial assistance from USAID, and that with respect to the award for which application
is being made, it will comply with the requirements of:

(1) Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352, 42 U.S.C. 2000-d), which prohibits
discrimination on the basis of race, color, or national origin, in programs and activities receiving Federal financial
assistance;

(2) Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), which prohibits discrimination on the
basis of handicap in programs and activities receiving Federal financial assistance;

(3) The Age Discrimination Act of 1975, as amended (Pub. L. 95-478), which prohibits discrimination
based on age in the delivery of services and benefits supported with Federal funds;

(4) Title IX of the Education Amendments of 1972 (20 U.S.C. 1681, et seq.), which prohibits
discrimination on the basis of sex in education programs and activities receiving Federal financial assistance (whether
or not the programs or activities are offered or sponsored by an educational institution); and

(5) USAID regulations implementing the above nondiscrimination laws, set forth in Chapter II of Title
22 of the Code of Federal Regulations.

(b) If the applicant/recipient is an institution of higher education, the Assurances given herein extend to admission
practices and to all other practices relating to the treatment of students or clients of the institution, or relating to the
opportunity to participate in the provision of services or other benefits to such individuals, and shall be applicable to the
entire institution unless the applicant/recipient establishes to the satisfaction of the USAID Administrator that the
institution's practices in designated parts or programs of the institution will in no way affect its practices in the program
of the institution for which financial assistance is sought, or the beneficiaries of, or participants in, such programs.

(c) This assurance is given in consideration of and for the purpose of obtaining any and all Federal grants, loans,
contracts, property, discounts, or other Federal financial assistance extended after the date hereof to the
applicant/recipient by the Agency, including installment payments after such date on account of applications for
Federal financial assistance which were approved before such date. The applicant/recipient recognizes and agrees that
such Federal financial assistance will be extended in reliance on the representations and agreements made in this

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Rev. 02/2012
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Assurance, and that the United States shall have the right to seek judicial enforcement of this Assurance. This
Assurance is binding on the applicant/recipient, its successors, transferees, and assignees, and the person or persons
whose signatures appear below are authorized to sign this Assurance on behalf of the applicant/recipient.

2. CERTIFICATION REGARDING LOBBYING

The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any
person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any
Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative
agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan,
or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing
or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or
cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure of Lobbying
Activities,"2 in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for all
subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements)
and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or
entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by
section 1352, title 31, United States Code. Any person who fails to file the required certification shall be subject to a
civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

3. CERTIFICATION REGARDING TERRORIST FINANCING

By signing and submitting this application, the prospective recipient provides the certification set out below:

1. The Recipient, to the best of its current knowledge, did not provide, within the previous ten years, and will
take all reasonable steps to ensure that it does not and will not knowingly provide, material support or resources to
any individual or entity that commits, attempts to commit, advocates, facilitates, or participates in terrorist acts, or
has committed, attempted to commit, facilitated, or participated in terrorist acts, as that term is defined in paragraph
3.

2. The following steps may enable the Recipient to comply with its obligations under paragraph 1:

a. Before providing any material support or resources to an individual or entity, the Recipient will
verify that the individual or entity does not (i) appear on the master list of Specially Designated Nationals and
Blocked Persons, which list is maintained by the U.S. Treasury’s Office of Foreign Assets Control (OFAC) and is
available online at OFAC’s website: http://www.treas.gov/offices/eotffc/ofac/sdn/t11sdn.pdf, or (ii) is not included
in any supplementary information concerning prohibited individuals or entities that may be provided by USAID to
the Recipient.

b. Before providing any material support or resources to an individual or entity, the Recipient also
will verify that the individual or entity has not been designated by the United Nations Security (UNSC) sanctions
committee established under UNSC Resolution 1267 (1999) (the “1267 Committee”) [individuals and entities linked
to the Taliban, Usama bin Laden, or the Al Qaida Organization]. To determine whether there has been a published

2
Available on the internet at: http://www.whitehouse.gov/omb/grants/sflllin.pdf.
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designation of an individual or entity by the 1267 Committee, the Recipient should refer to the consolidated list
available online at the Committee’s website: http://www.un.org/Docs/sc/committees/1267/1267ListEng.htm.

c. Before providing any material support or resources to an individual or entity, the Recipient will
consider all information about that individual or entity of which it is aware and all public information that is
reasonably available to it or of which it should be aware.

d. The Recipient also will implement reasonable monitoring and oversight procedures to safeguard
against assistance being diverted to support terrorist activity.

3. For purposes of this Certification-

a. “Material support and resources” means currency or monetary instruments or financial securities,
financial services, lodging, training, expert advice or assistance, safehouses, false documentation or identification,
communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, and other
physical assets, except medicine or religious materials.”

b. “Terrorist act” means-

(i) An act prohibited pursuant to one of the 12 United Nations Conventions and Protocols
related to terrorism (see UN terrorism conventions Internet site: http://untreaty.un.org/English/Terrorism.asp); or

(ii) An act of premeditated, politically motivated violence perpetrated against noncombatant

targets by subnational groups or clandestine agents; or

(iii) Any other act intended to cause death or serious bodily injury to a civilian, or to any other
person not taking an active part in hostilities in a situation of armed conflict, when the purpose of such act, by its
nature or context, is to intimidate a population, or to compel a government or an international organization to do or
to abstain from doing any act.

c. “Entity” means a partnership, association, corporation, or other organization, group or subgroup.

d. References in this Certification to the provision of material support and resources shall not be
deemed to include the furnishing of USAID funds or USAID-financed commodities to the ultimate beneficiaries of
USAID assistance, such as recipients of food, medical care, micro-enterprise loans, shelter, etc., unless the Recipient
has reason to believe that one or more of these beneficiaries commits, attempts to commit, advocates, facilitates, or
participates in terrorist acts, or has committed, attempted to commit, facilitated or participated in terrorist acts.

e. The Recipient’s obligations under paragraph 1 are not applicable to the procurement of goods
and/or services by the Recipient that are acquired in the ordinary course of business through contract or purchase,
e.g., utilities, rents, office supplies, gasoline, etc., unless the Recipient has reason to believe that a vendor or supplier
of such goods and services commits, attempts to commit, advocates, facilitates, or participates in terrorist acts, or
has committed, attempted to commit, facilitated or participated in terrorist acts.

This Certification is an express term and condition of any agreement issued as a result of this application, and any
violation of it shall be grounds for unilateral termination of the agreement by USAID prior to the end of its term.

4. DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER

(a) In the space provided at the end of this provision, the recipient should supply the Data Universal Numbering
System (DUNS) number applicable to that name and address. Recipients should take care to report the number that
identifies the recipient's name and address exactly as stated in the proposal.

(b) The DUNS is a 9-digit number assigned by Dun and Bradstreet Information Services. If the recipient does not
have a DUNS number, the recipient should call Dun and Bradstreet directly at 1-800-333-0505. A DUNS number
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will be provided immediately by telephone at no charge to the recipient. The recipient should be prepared to provide
the following information:

(1) Recipient's name.

(2) Recipient's address.
(3) Recipient's telephone number.
(4) Line of business.
(5) Chief executive officer/key manager.
(6) Date the organization was started.
(7) Number of people employed by the recipient.
(8) Company affiliation.

(c) Recipients located outside the United States may e-mail Dun and Bradstreet at globalinfo@dbisma.com to obtain
the location and phone number of the local Dun and Bradstreet Information Services office.

The DUNS system is distinct from the Federal Taxpayer Identification Number (TIN) system.

DUNS: ________________________________________

5. TAXPAYER IDENTIFICATION NUMBER (TIN)

If the applicant/recipient is a U.S. organization, or a foreign organization which has income effectively connected with
the conduct of activities in the U.S. or has an office or a place of business or a fiscal paying agent in the U.S., please
indicate the applicant's/recipient's TIN:

TIN: ________________________________________________________________________________________

6. LETTER OF CREDIT (LOC) NUMBER

If the applicant/recipient has an existing Letter of Credit (LOC) for payment purposes, please indicate the LOC
number:

LOC: ________________________________________________________________________________________

7. CENTRAL CONTRACTOR REGISTRATION (CCR)

All grantees must have a current registration in the CCR database. Please list your CCR expiration date below:

CCR Expiration Date: _______________________________________________________________________

8. BANKING INFORMATION

If the applicant/recipient has not had a USAID award before, please attach banking information to which payments will
be made. Such information should include, at a minimum, bank name, bank address, ABA number, and account
number. Unless payment is by Letter of Credit, USAID will make payments via electronic funds transfer. However,
USAID’s system provides for electronic funds transfers to U.S. banks only. Therefore, if the applicant/recipient is a
non-U.S. organization, the applicant/recipient must provide the name and banking information for a U.S. bank that
will receive funds on its behalf.

9. POINT(S) OF CONTACT

Please enter the information below for the applicant’s/recipient’s authorized point(s) of contact:

Name Title Telephone No. Fax No. E-Mail Address

_______________________________________________________________________________________________
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_______________________________________________________________________________________________
_______________________________________________________________________________________________

10. SIGNATURE

By signature hereon, or on an application/proposal incorporating these Certifications, Assurances, and Other

Statements of Applicant/Recipient, the applicant/recipient represents that: (a) they are accurate, current and complete;
(b) the person signing below is authorized to sign on behalf of the applicant/recipient; and (c) the applicant/recipient is
aware of the penalty prescribed in 18 U.S.C. 1001 for making false statements in applications/proposals.

Solicitation No. (If Applicable) _____________________________________________________________________

Application/Proposal Title ________________________________________________________________________

Application/Proposal No. (If Applicable) _____________________________________________________________

Date of Application/Proposal ______________________________________________________________________

Name of Applicant/Recipient ______________________________________________________________________

Typed or Printed Name and Title ___________________________________________________________________

Signature ______________________________________________________ Date __________________________